Improving outcomes in patients with Acute Kidney Injury: the impact of hospital based automated AKI alerts.

BACKGROUND: Acute kidney injury (AKI) is a significant cause of morbidity and mortality. Early identification may improve the outcome and in 2012 our hospital introduced an automated AKI alert system for early detection and management of AKI. OBJECTIVES: Using an automated AKI alert system we analysed whether early review and intervention by the Critical Care and Outreach (CCOT) team improved patient outcomes in AKI and whether serum bicarbonate was useful in predicting outcomes in patients with AKI. METHODS: In a retrospective analysis we identified patients who triggered an AKI alert from 20 April 2012 to 20 September 2013 and collected data on mortality, length of stay, need for intensive care admission and renal replacement therapy (RRT). RESULTS: 994 AKI alerts were generated and analysed. Patients with bicarbonate outside the normal range had significantly higher mortality. Bicarbonate <22 mmol/L was associated with a mortality of 25.7% (49/191) compared with 16.9% (39/231) when 22-29 mmol/L (p=0.047, χ(2)). Those patients reviewed ≥1 day after AKI alert by CCOT compared with those seen on the day of the alert had a 2.4 times increase in mortality and were 7 times more likely to require RRT acutely. CONCLUSIONS: Electronically identified AKI alerts identify patients at high risk of morbidity and mortality. In this group AKI alerts preceded CCOT review by a mean of 2 days. This represents a window for supportive interventions, which may explain improved outcomes in those reviewed earlier. The addition of serum bicarbonate offers a further method of risk stratifying patients at greater risk of death.

Criminality among individuals arraigned for drinking and driving in Massachusetts.

Criminal record searches of 1406 randomly selected driving under the influence of liquor (DUIL) offenders in Massachusetts revealed a history of prior court arraignments in 76.5% of the cases. Half (51.2%) had been arraigned for criminal offenses other than or in addition to traffic and DUIL, and one-fourth (27.7%) had been previously arraigned for DUIL. Among those with prior DUIL arrests, 68% also had criminal arrests. A 3-year follow-up indicated that 63% of those rearrested for DUIL had prior criminal arrests. Eight subgroups of offenders were created by categorizing the sample according to the presence or absence of criminal, traffic and prior DUIL offenses. Rates of recidivism differed among the subgroups and illustrated the utility of using criminal history data to differentiate DUIL offenders. The need to develop alternative court management-rehabilitation strategies responsive to subgroup differences is discussed.

Legislated policies and recidivism for driving under the influence of liquor in Massachusetts.

Legislation on driving under the influence of liquor was changed significantly in Massachusetts on 1 December 1975; it permitted courts to continue cases without a finding if defendants were place probation and assigned to driver alcohol education. The effect of the revisions on the incidence of rearrest was assessed. The 3-yr arrest records of 522 individuals arrested for drunken driving 2 yr before the changes (1973) were compared with 716 and 690 offenders arrested 1 (1976) and 2 (1977) yr post-law modification. Sample participants were selected randomly. The legislation strongly affected court dispositions. Over 70% of the 1976-1977 cases were continued without findings and more offenders were sanctioned. The proportion found not guilty dropped from 1973 to 1976-1977. Absolute rearrest rates were similar for each cohort. Probability of arrest, however, rose substantially between 1973 and 1980. Relative to the increased arrest rate, there was a significant decline in rearrests 2 and 3 yr after a drunken driving arrest during the post-law period. The legislation apparently contributed to an amelioration of the drunken driving problem by encouraging judicial reforms and educational interventions.